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CPT
12/14 Hip
System
®
Femoral Impaction
Grafting in Revision THR
Surgical Technique
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
SURGICAL TECHNIQUE FOR FEMORAL IMPACTION GRAFTING
IN REVISION THR USING CPT 12/14 HIP SYSTEM
CONTENTS
INTRODUCTION.........................................4
Tamp Assembly..................................15
DESIGN PHILOSOPHY...............................5
Establishing a Bone Reference Point..16
Collarless Polished Taper Design........5
System Size Offering..........................5
Determination of Distal Femoral
Packer................................................17
CPT Femoral Impaction
Grafting Technique.............................5
Guide Wire and Intramedullary Bone
Plug Insertion.....................................18
Distal Graft Packing............................19
PREOPERATIVE PLANNING........................11
Distal Graft Preparation for a Long
Stem Component................................20
SURGICAL TECHNIQUE..............................12
Impaction with Femoral Tamps...........21
Approach............................................12
Monoblock Tamping...........................22
Osteotomies.......................................12
Trial Reduction....................................22
Determination of Leg Length...............12
Proximal Bone Reconstruction............23
Dislocation, Removal of Components,
and Acetabular Implantation .............12
Modular Tamping...............................23
Selection of the Procedure.................12
Proximal Packing and Torque Test......24
Reconnect Tamp.................................25
Cement Application............................26
20 STEPS FOR IMPACTION GRAFTING........6
IMPACTION GRAFTING PROCEDURE..........13
Bone Graft Preparation.......................14
Preparation of Graft Site ....................14
Determination of Stem Size and
Length................................................14
Implantation.......................................26
Wound Closure...................................28
REFERENCES.............................................29
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Introduction
Since the introduction of femoral impaction grafting for stem
revision in the early 1990s, there have been numerous reports
of mid-term clinical success reported in the literature.1-14 While
impaction grafting is technically demanding, and there have been
adverse reports,15-17 it is now recognized that there are distinct
advantages to the technique, including both preservation of bone
and remodeling of impacted bone graft to living bone.18-21
4.Use Proximal Tamp to impact and pack proximal graft.
Despite the success of femoral impaction grafting, even in salvage
situations, two types of complications; component subsidence
and periprosthetic fracture, have been reported.15,22,24 It is now
recognized that the risk of complications can be minimized by
well-designed instruments and surgical technique. Important
techniques in femoral impaction grafting include the use of an
instrument system which both simplifies the technique and
enhances distal bone packing30 while providing an adequate
cement mantle.31,32 It is important to protect areas of bone loss36
by having available a comprehensive range of standard stems
and to use longer stems when necessary. Several other factors
are thought to be important by some authors, including choice
of graft material.25-29 Historically, fresh-frozen allograft has been
used with success, while washing the graft and other techniques
have also been proposed.30,34 The use of onlay allograft struts35
has also been reported, and avoidance of distal stress risers30 is
recommended.
An important advantage of using femoral impaction grafting and a
cemented stem in younger and middle-aged patients is that the
femur can be revised in many cases using a standard length
stem, thereby not transgressing the isthmus of the femur and so
minimizing stress shielding, thigh pain, and future problems of
revision of a long stem.
The enhanced CPT 12/14 System addresses the above issues by
providing a modular impaction system to simplify the technique
while also permitting an optimized cement mantle and providing
an expanded range of standard stems, with the option of three
offsets and a comprehensive range of long stems and extended
offsets.
The innovative CPT 12/14 Modular Tamping System simplifies
femoral impaction grafting. This system has a broad range of sizes
to address the difficult revisions, and is designed to provide a
simple four-step impaction process:
1.Pack graft with Distal Femoral Packers.
2.Impact graft with assembled Femoral Tamps.
3.Remove Guide Wire and perform trial reduction.
Impaction grafting can be used routinely for revision, and the
clinical results when the technique is used at first revision are
excellent.1, 4, 5, 9-12 Also, impaction grafting can be used selectively
when other techniques are less desirable, such as: cases involving
a large canal with osteoporotic bone which will not support a large
cementless stem, cases of angular deformity, cases where there is
a distal TKR stem, or cases involving patients who are having their
third or fourth revision.22,23
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
5
Design Philosophy
Collarless Polished Taper Design
Collarless, polished tapered stems can be used for impaction
grafting and have been the stem of choice for revision surgeons
using impaction grafting techniques. Collarless, polished tapered
stems have proven to be successful during more than 25 years
of clinical use in primary hip arthroplasty.37-41 The CPT 12/14
Hip System has continued this tradition of success since the
introduction of the original CPT Hip stem more than a decade
ago.37, 40-42 The combination of a collarless prosthesis with a highly
polished surface and double taper wedge allows the prosthesis
to slightly subside within the cement mantle to achieve a strong,
self-locking construct.
of the reconstructed hip. In particular, the valgus neck stems
can be used to accommodate two common scenarios in revision
surgery: a high hip center or proximal femoral bone loss. The three
longer stems, 200mm (+70mm), 230mm (+100mm), and 260mm
(+130mm), are used for more severe proximal and distal bone
damage. These stems have a distinctive dual-taper design in that
they maintain the double taper principle of the collarless tapered
stem, but have two consecutive tapers from proximal to distal.
The proximal taper blends into the stem taper. The dual taper
is designed to maximize the advantages of a tapered cemented
stem.
System Size Offering
The technique of cemented long stem revision is successful
at long term and is applicable in many routine revisions.43 In
middle aged and younger patients, where bone restoration
is a priority, or in cases of major bone loss, or where a long
stem is contraindicated, the CPT 12/14 Stem can be combined
successfully with impaction grafting using the CPT 12/14 Femoral
Impaction Grafting Technique to help restore bone.
The CPT 12/14 Hip System includes primary and long stem
components (Table 1). Five primary stems, from size 1 through
size 5, are available in up to three offsets. Additionally, seven long
stem options, which include two valgus neck stems that provide
leg length options without altering offset, are available. The CPT
12/14 Hip System is available in Zimaloy® Colbalt-ChromiumMolybdenum Alloy only. Stem choices are listed below, along
with their length and, in parentheses, the number of millimeters
longer than the standard CPT 12/14 Hip Stem (sizes 1-5), which is
130mm. The stem length is defined as the distance from the stem
tip to the intersection of the medial curve and the osteotomy line.
CPT 12/14 Femoral Impaction Grafting Technique
The CPT Hip System has been used for more than a decade
to reconstruct the femur at revision surgery. The CPT 12/14
Impaction Grafting Instrumentation has been improved through
the design of modular tamps, which provide a means of impacting
allograft distally, then impacting proximally. The modular system
allows the surgeon first to concentrate on reconstruction of the
femur, then to establish leg length and stability, and finally to
focus on proximal impaction. The long stem range has been
expanded to include seven long stems.
The long-stem CPT 12/14 Components are of two types, those
with a continuous taper, and the longer stems with a dual taper.
The four 180mm (+50mm) long stems have a continuous taper
from proximal to distal and are suitable for many routine revisions.
The two valgus neck (VN) stems are important because they allow
for more options in adjusting neck length and center of rotation
Offset
Stem Size
Stem Length
Standard
Extended
Size 1
130mm
X
X
Size 2
130mm
X
X
X
Size 3
130mm
X
X
X
Size 4
130mm
X
X
X
Size 5
130mm
X
X
X
Size 2, 180mm
180mm (+50mm)
X
Size 2, 180mm VN
180mm (+50mm)
X
Size 3, 180mm
180mm (+50mm)
X
Size 3, 180mm VN
180mm (+50mm)
X
Size 4, 200mm
200mm (+70mm)
X
Size 4, 230mm
230mm (+100mm)
X
Size 4, 260mm
260mm (+130mm)
X
Table 1
Extra-Extended
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
20 STEPS FOR IMPACTION GRAFTING
1. Preoperative Planning
Template to provide a basis for judging appropriate
reconstructive, leg length, and offset targets to achieve
during surgery.
2. Approach
Expose the hip joint using your approach of choice.
More extensive exposure is required for impaction
grafting surgery.
3. Leg Length Measurement
and Component Removal
Prior to dislocating the hip, obtain a baseline
measurement of leg length using your preferred
method. Carefully dislocate the hip and remove the
acetabular and femoral components, bone cement, and
residual membranes.
4. Acetabular Component
Proceed to implantation of the acetabular component
and note new center of hip rotation.
5. Prepare Bone Graft and Graft Site
Prepare the bone graft chips and cancellous cubes.
Contain any distal bone defects with mesh and
cerclage wire. Clear and cleanse the proximal femoral
canal. This can often be completed by using an
oversized Rasp laterally. A proximal femur cerclage
wire, or a temporary cable may be applied instead of a
surgical mesh.
6. Choose Stem
The stem should extend to a depth that is twice the
femur diameter beyond the most distal cortical defect.
Stem
Length
Standard
Offset
Extended
Offset
Extra
Extended
Offset
130mm
Size 1-5
Size 1-5
Size 2-5
180mm
Size 2
Size 3
200mm
Size 4
230mm
Size 4
260mm
Size 4
Valgus
Neck
Size 2,3
7. Identify Starter Tamp
Assemble a number of Tamp Assemblies using Locking
Screws and the Locking Rod. Insert the largest possible
Tamp Assembly, to the intended depth in the femur, in
the correct version and varus/valgus position. This will
be designated the “Starter Tamp.” The “Final Tamp” is
usually one or two sizes smaller than the Starter Tamp.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
8. Establish Bone Reference Point
Undertake trial reduction with a rasp/trial or an
assembled tamp to determine the correct depth of stem
insertion. Mark the level where the lateral shoulder of
the tamp or rasp meets the medial side of the greater
trochanter. This is the “Bone Reference Point”.
10. Guide Wire and Bone Plug Insertion
Thread the Guide Wire onto the bone plug and slide
the Starter Packer over the Guide Wire. Insert the
bone plug to the appropriate bone plug depth mark
on the packer, ie “130 Plug,” “180 Plug,” etc. If a
distal bone pedestal or retained cement is used
as a plug, drill the Guide Wire using the packers to
centralize.
Locking
Screw
Bone
Reference
Point
Step 8
9. Identify Starter Packer
insert the largest possible diameter
Distal Femoral Packer to the bone
plug depth. This is the Starter Packer.
Step 9
Step 10
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
20 STEPS FOR IMPACTION GRAFTING
11. Distal Graft Packing
Introduce 10cc of bone graft chips.
Beginning with the Starter Packer,
impact the graft. Sequentially add 5cc of
morselized allograft between packing.
Pack the distal graft until the “Distal
Pack” mark on the Distal Femoral Packer
is level with the Bone Reference Point.
Graft Corers are available to remove
graft, if necessary.
If using primary stems, use the next smaller size tamp
assembly from the Starter Tamp. Continue alternating
graft insertion and
tamping until the
desired final tamp
size is stable. Remove
the Guide Wire and
Rasp Handle. Perform
a trial reduction for
leg length, stem
orientation, and
choose offset.
Note: If using
a VerSys® Trial
Head, refer to
the Zimmer
VerSys Trial
Head Surgical
Technique 978018-001-00
for additional
information.
Step. 11
Step. 13
12. Femoral Tamp Impaction
Introduce 5cc of allograft and
begin hand packing with the
Starter Tamp
as defined in Step 7.
Alternately add 5cc
of allograft and tamp,
checking anteversion
each time. Impact
until the shoulder of
the Starter Tamp is
level with the Bone
Reference Point. With
the tamp in place,
apply proximal mesh
if necessary and
not already applied.
Continue grafting
and tamping until the
entire canal is lined
circumferentially with
impacted allograft.
13. Final Tamp and Trial Reduction
14. Proximal Bone Reconstruction
If depth of insertion or position requires adjustment,
reinsert the Guide Wire and retamp. Otherwise, leave
the Final Tamp in place, modularize the tamp and
undertake proximal graft impaction.
Step. 12
Note: Do not use the MIS CPT Rasp Handle
(00-8334-081-00) with any impact grafting
instruments.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
15. Proximal Graft Impaction
Disassemble the Final Tamp by removing the
Locking Screw and thread the Guide Rod Extension
through the Proximal Tamp and into the Distal
Tamp. Partly withdraw the Proximal Tamp up to the
double-line mark on the Guide Rod and pack 5cc of
allograft around the proximal Tamp by hand with the
Proximal Packers. To pack a large amount of graft
proximally, remove the Proximal Tamp and insert
graft. Otherwise, withdraw the Proximal Tamp. Using
a mallet, impact the graft by impacting the Proximal
Tamp down to reach the Distal Tamp, determined
by when the single line on the Guide Rod becomes
visible. Continue alternating graft insertion and
Proximal Tamp impaction until the proximal canal is
evenly and solidly packed with allograft.
16. Final Proximal Packing and
Torque Test
Step. 15
Withdraw the Proximal Tamp about
1cm and use the Proximal Packers to
impact cancellous cubes (5mm x 5mm
x 10mm and 5mm x 5mm x 5mm) and
smaller allograft pieces. Then reseat the
Proximal Tamp.
Test the tamp in the posterior direction
to between 40 and 50 in.-lbs. If the tamp
moves, perform further impaction.
Step. 16
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
20 STEPS FOR IMPACTION GRAFTING
17. Reconnect Tamp
When the tamp is stable, remove the Guide Rod
Extension. Reconnect the Locking Rod and tighten with
the screw-driver. Withdraw the assembled tamp a few
millimeters and reinsert. Retighten the Locking Rod.
Then withdraw the Tamp Assembly 1cm and reseat the
tamp gently.
19. Implantation
Assemble the stem onto the Stem Inserter, then attach
the wingless Revision Distal Centralizer. Slowly insert
the stem to the appropriate position while maintaining
axial alignment and anteversion. Perform a trial
reduction. Attach the femoral head.
Step. 17
18. Cement Application
Remove the Tamp Assembly. Place
Horsecollar over proximal graft.
Fill the canal with cement in a
retrograde fashion, and pressurize
the cement.
Cement Restrictor Plate
(optional use)
Step. 19
20. Wound Closure
Close the wound in layers.
Step. 18
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Preoperative Planning
Comprehensive preoperative planning is helpful in revision
surgery to prepare for a variety of potential circumstances.
This begins with careful preoperative templating. Template
the femur and plan stem length, depth of insertion, bone
plug site, extent of bone grafting, and the need for proximal
reconstruction. These may need to be modified according
to intraoperative findings, but provide a base for planning.
Begin by obtaining a complete set of good quality
radiographs, including:
The purpose of preoperative templating is to:
Note the important reference points on the radiographs,
including:
1. Gain an accurate three-dimensional understanding of
the bony anatomy and cortical defects.
2. Estimate the stem size and length and the site of the
distal bone plug, or the possibility of using an existing
bone pedestal or retained distal cement as a plug.
3. Determine the possible centers of rotation
of the reconstruction (anatomic or new hip
center).
4. Predict limb lengths based on the hip center, and
the height of the calcar and lesser trochanter,
in conjunction with clinical measurement and
preoperative radiographs.
5. Determine the appropriate relationship between the
height of the tip of the trochanter or other lateral
landmark, and the center of femoral head rotation.
6. Determine potential difficulties in implant removal
and insertion.
7. If necessary, plan the level and type of femoral
or trochanteric osteotomy, and the bed for its
reattachment.
8. Determine the need for bone mesh
containment for reconstruction of proximal
or distal cortical defects.
In femoral templating, it is important to appreciate that
magnification of the size of the femur will vary depending
on the distance from the x-ray source to the film and the
distance from the patient to the film. The CPT Hip System
Templates use standard 20 percent magnification, which
is close to the average magnification on most clinical
x-ray films. Magnification for larger patients or obese
patients may be greater than 20 percent because their
osseous structures are farther away from the surface of
the film. To determine the magnification of any x-ray film,
use a standardized marker at the level of the femur when
exposing the film.
1. An A/P of the pelvis centered on the pubis.
2. An A/P and lateral of the length of the femur.
For patients with acetabular bone deficiency, obturator and
iliac oblique views may be helpful.
1. The existing center of rotation of the failed hip
arthroplasty.
2. The location of the anatomic center of rotation of
the hip (based on the contralateral hip, preoperative
views of the failed hip, or using the teardrop and
Kohler’s lines for reference).
3. The offset of the failed hip arthroplasty.
4. The normal offset.
5. The level of the calcar.
6. The height of the tip of the greater trochanter, or
other lateral landmark, in relation to the center of the
femoral head.
In addition, assess any acetabular and femoral bone
deficiencies or angular deformities of the femur, and all
other factors related to the failed implant.
Template for the acetabular component first. In the
absence of any significant bone deficiencies, select the
hemispherical acetabular transparency that makes the best
circumferential contact with the remaining bone stock,
positioning the implant in appropriate abduction. If there
is major bone loss or socket break-out, template for either
a smaller acetabular component at a higher than normal
hip center, or a close-to-anatomic center with the use of
a large hemispherical component reconstruction cage,
segmental allograft, or Trabecular Metal™ implant. Indicate
these possibilities as potential centers of rotation on the
radiographs.
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Next, template for the femoral component to determine its
optimum size and length, as well as its position. Please
note, CPT 12/14 Stems should not be seated proud for
impaction grafting procedures. Clearly delineate areas of
major osteolysis, stress risers, femoral perforations, and
points of angulation or malrotation, all of which influence
the size and length of the stem required. Determine the
extent of bone grafting, if required, and the need for
proximal reconstruction with mesh, distal containment of
defects with mesh, and the use of strut allografts. These
may have to be modified intraoperatively, but will provide a
base for planning.
Select the template that best fits the proximal femur,
leaving room for bone graft and cement. The outline of the
prosthesis is indicated by a solid line and the outline of the
cement mantle created by the rasp is indicated by a dashed
line on the template. Align the femoral template so that it
is centered in the diaphysis and then move the template so
that the center of the femoral head and the osteotomy line
are appropriately positioned to restore the planned amount
of leg length. While aligning the femoral template in the
canal, the presence of incongruities or an excessive bow or
angulation in the A/P or lateral planes will become evident.
After indicating the planned center of rotation on the
radiograph, and the proper position of the femoral
component, determine the optimal head position and stem
offset. By having the choice of a standard neck angle or a
valgus neck angle, the 180mm stems allow versatility in the
choice of neck height and hip center. A valgus neck stem,
which provides an additional 15mm of leg length, may be
used to gain leg length in a high hip center, or to provide a
stronger construct by seating the stem distally in bone.
When templating, and intraoperatively, aim to achieve leg
length without using the longer heads, which have a skirt.
These are reserved for situations where an unplanned
increase in leg length is required.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
SURGICAL TECHNIQUE
Approach
Position the patient for routine hip surgery. Extensive
exposure is recommended, especially in difficult revision
cases.
Osteotomies
An approach using trochanteric osteotomy is not routinely
advised before impaction grafting because it removes the
lateral support for grafting and for attaching medial mesh.
If necessary, however, a trochanteric slide can be useful for
difficult exposure, and an extended trochanteric approach
can be used to remove femoral components. If an extended
trochanteric osteotomy is performed, plan to use a long
stem, and reduce the osteotomy, holding it with cables
prior to impaction grafting.
Determination of Leg Length
After exposing the joint, obtain a baseline leg length
measurement before dislocating the hip. There are several
methods to measure leg length. One method is to place
one pin in the iliac wing and a cautery mark or a pin in the
greater trochanter. With the leg in the neutral position,
measure the distance between the two reference points. It
is important that the measurement be taken with the leg
in the neutral position so the position can be easily and
accurately reproduced after the new implant has been
inserted. Leave the proximal pin in place, but remove
the trochanteric pin, if used, and mark the pin site with
electrocautery so it can be replaced for remeasurement.
Dislocation, Removal of Components, and
Acetabular Implantation
Carefully dislocate the hip to avoid the risk of fracture of
the sometimes fragile femoral bone stock. Remove the
implants and insert the acetabular component. Note the
new center of hip rotation.
Selection of the Procedure
Inspect the metaphyseal and diaphyseal regions for
a neocortex, sclerotic bone formation, and remaining
bone cement in the case of a cemented implant. Use
this information to choose the appropriate procedure for
femoral preparation. If using a standard revision technique,
proceed with the Surgical Technique for Femoral Revision.
If using an impaction grafting technique, proceed with the
surgical technique outlined here.
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
IMPACTION GRAFTING PROCEDURE
Impaction grafting has been shown to reconstitute bone
in revision situations. The CPT 12/14 Hip System includes
modular impaction grafting instruments that enhance as
well as simplify the technique.
Among the key instruments in the impaction grafting
instrument set are (Fig. 1):
•
Distal Femoral Packers, which are cannulated larger
diameter rods used initially to pack the distal allograft
area.
•
Corers, which are designed to remove excessive
graft or cylindrical plugs of graft up to 7cm long, are
supplied for complicated cases and the use of longer
stems.
•
Tamps for primary stem sizes 1-5; long stem sizes 2,
180mm; 3, 180mm; and 4, 200mm through 260mm
are available as modular instruments. Each Tamp
Assembly consists of a proximal Tamp, a distal Tamp,
and a Locking Screw or Locking Rod. The proximal
Tamp is fixed to the distal Tamp with the Locking
Screw or Locking Rod. The Tamp Assembly is initially
used as a monoblock Tamp. While the Locking Screw
and Locking Rod perform the same function, the
Locking Rod is longer to facilitate its application
and tightening when access to the proximal Tamp is
difficult.
Several essential items specific to impaction grafting
should be available during surgery. These include:
1. Morselized bone chips from at least two fresh, frozen,
or irradiated femoral heads, although more may be
needed in cases with severe bone loss. The allograft
should be obtained only from a recognized bone bank
and it is helpful if the supply is local should more be
needed intraoperatively.
2. A sterile bone mill to convert the femoral heads to
bone chips of manageable size if this has not been
performed preoperatively.
3. The CPT 12/14 Primary Instrument Set, the CPT 12/14
Revision Supplementary Instrument Set, and the CPT
12/14 Impaction Grafting Instrument Set.
Fig. 1
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
4. The appropriate size implants. The CPT 12/14 Hip
System offers primary sizes with regular, extended,
and extra-extended offsets, as well as long stem sizes
with standard and valgus neck angles and extra long
stems with a dual taper design. The size 0, small,
and extra-small are not recommended for impaction
grafting. A long stem should be considered for
distal bone defects or severe deficiencies, including
defects requiring mesh reconstruction that extend
below the lesser trochanter or defects involving more
than half the femoral circumference, making mesh
reconstruction less secure.
5. A medullary bone plug and standard bone cement
accessories.
6. A supply of reconstruction meshes, cerclage wires,
and cables.
Bone Graft Preparation
Two to three femoral heads are usually needed. Remove
soft tissue from the femoral heads and conservatively
remove the articular cartilage while preserving subchondral
bone. The ideal size of bone chips ranges from less
than 1mm up to 4mm for intramedullary impaction.
Approximately half a femoral head should be divided with
a saw into 5mm x 5mm x 5mm and 5mm x 5mm x 10mm
cancellous cubes for final packing into the proximal femur
at the osteotomy level. There are a number of techniques
to further prepare bone. One technique is to wash the
bone chips in saline heated to 45°C, then strain over a 200
micron strainer or pack. Add antibiotic powder if desired.
It is always advisable to have additional allograft material
available in case it is needed intraoperatively. During
impaction, bone chips should be delivered 5cc at a time by
using a spoon or alternating 10cc syringes with their ends
cut off.
Preparation of the Graft Site
Remove the proximal femoral contents, and thoroughly
clear and cleanse the femoral canal. Expose the femur
and shield the surrounding tissues with gauze. Cement
remaining in the distal canal can be used as a plug if it is
distal enough, well fixed, more than 2cm below significant
cortical bone damage, and infection has not been present.
At this stage, inspect the femur for cortical defects and
contain distal defects with mesh and cerclage wire or cable.
Choose a stem that is long enough to extend beyond distal
areas of cortical deficiency. Also, the stem should extend
beyond distal wires or cables applied around a femur
with thin cortices because these may act as a stress raiser
unless a strut graft is applied.
A cerclage wire is usually applied to the proximal femur for
protection of the femur during trial reduction and impaction.
The Zimmer Cable-Ready® Cable Grip System cable may be
temporarily locked in place and later unlocked to hold the
mesh. Note that a wire may be preferable to a cable in the
proximal region, adjacent to the joint.
Begin by ensuring bone is adequately removed from the
trochanter so as to enhance axial alignment by using a
gouge, rongeurs, rasps, or a power burr. Use primary or
long stem rasps to rasp laterally. Gently remove bone from
the femur as necessary to partially or fully seat the rasp.
If desired, a primary or long stem rasp can be used to
prepare the femoral canal and remove bone laterally. The
rasp can also be used for trial reduction to determine
and provide the depth of insertion of the stem while
simultaneously providing an estimate of leg length. If the
rasp is not stable, insert the Trial Locating Pin through the
depth holes in the rasp and combine this with lap pads
to stabilize the rasp in the canal. After determining depth
of insertion, mark a “Bone Reference Point” as described
below. Note that the tamps for the primary and 180mm stems
are larger than the rasps so the rasps should not be used to
assess tamp size.
If a proximal mesh is required, impact the distal canal up
to the proximal extent of the femur and apply the mesh.
Mold the mesh around any residual lesser trochanter or,
if preferred, trim the lesser trochanter flat with a saw.
Use wires and cables to anchor the mesh. A wire may be
preferable to cable in the proximal region, adjacent to
the joint. If a trochanteric slide or osteotomy has been
undertaken, the lateral deficiency can be restored in its
distal part by using a lateral mesh, and the trochanter
reattached after the stem has been cemented.
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Determination of Stem Size and Length
Determine the stem length required based on the extent of
bone loss observed during preoperative and intraoperative
assessment. A long stem component is recommended for
significant proximal and/or distal deficiencies. As a guide,
the stem should extend beyond the most distal cortical
defect two femur diameters. The graft should be contained
by bone or mesh up to the osteotomy. In the absence of
distal defects, a standard stem with or without mesh is
often used. When there is major deficiency proximally or
distally, a long stem is recommended. If a trochanteric
slide or osteotomy has been necessary, the rotational
stability of the impaction grafting is somewhat lessened
and a longer than standard stem may be indicated.
The CPT 12/14 System includes primary stems sizes 1
through 5 (130mm long) and seven long revision stem
options. Sizes 2, 180mm and 3, 180mm are available in
a valgus neck configuration. The advantage of the valgus
neck stems is additional leg length without additional
offset, which may be advantageous in revision surgery.
Size 4 long stems are available in 200mm, 230mm, and
260mm lengths.
Tamp Assembly
Assemble the modular femoral tamps using either the
Locking Screw or Locking Rod (Fig. 2). Both can be slightly
tightened with a hex-head screwdriver. Use the Tamp
Assemblies to gauge the size of the canal. The Tamp
Assemblies are equivalent in size to the implant of the
same number plus an allowance for a relatively thick
cement mantle. For example, a size 3 Tamp Assembly
creates a cavity for a size 3 implant with cement.
Considering the planned depth of insertion and length of
stem, as well as any bone defects, determine the largest
Tamp Assembly that can be inserted in the femur in the
correct version and varus/valgus position.
It is important that the stem is aligned straight in the
femur to prevent varus positioning. Lateralization of the
femoral opening is usually required when a round-backed
prosthesis is being converted to a straight stem such as
the CPT 12/14 Stem. The insertion of the tamp can be
helpful to define the amount of bone dissection required
around the proximal opening. Excess bone can be removed
using a burr and femoral rasps.
It is necessary to ascertain the largest tamp, designated
the “Starter Tamp,” that can be inserted in the correct
position in the femur. The starter Tamp should be well
lateralized, in the correct varus/valgus alignment,
anteversion, and at the planned depth of insertion. The
length of the stem should take into account the bone
defects. The starter Tamp is chosen by beginning small
Fig. 2
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
and progressively increasing the tamp size. Use the starter
Tamp, or a larger Rasp to do a trial reduction for leg length
and offset check. This will also help to define the proposed
depth of insertion of the Tamp and stem. This should be
done gently.
Make an initial estimate of the final stem size that is likely,
based on preoperative templating and operative findings.
Designate the corresponding tamp as the “Final Tamp.”
This may be changed during the procedure. When using
standard 130mm length stems, the final Tamp is usually
one or two sizes smaller than the starter Tamp.
If the bone stock is inadequate at the greater trochanter,
use an alternative reference point such as the level of the
osteotomy cut, the medial calcar, or the lesser trochanter.
Note the distance from the “Alternative Reference Point”
to the shoulder of the Starter Tamp or the rasp used in trial
reduction (Fig. 4).
Establishing a Bone Reference Point
With the starter Tamp Assembly or a Rasp in place, mark
the level where the lateral shoulder of the tamp or rasp
meets the medial side of the greater trochanter (Fig. 3).
This is the recommended “Bone Reference Point” for depth
of insertion of the stem, as well as the bone plug, the Distal
Femoral Packers, and the Tamp Assemblies.
1.5cm
Fig. 4
Fig. 3
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Determination of Distal Femoral Packer
Determine the safe insertion depth for each Distal Femoral
Packer. Begin with the 10mm Distal Femoral Packer. Then
sequentially increase the size and record the largest Distal
Femoral Packer size that can be inserted to the intended
bone plug depth without impinging on the canal wall. This
is designated the “Starter Packer” and will be the first
Distal Femoral Packer used to impact the distal allograft.
If the femoral canal flares considerably above the intended
bone plug site, sequentially larger diameter Distal Femoral
Packers can be used as more allograft is added. Continue
to insert larger diameter Distal Femoral Packers and record
the depth that each can be inserted without impingement
on the cortical walls. Do not use these Distal Femoral
Packers until the impacted graft reaches these levels.
The extent of grafting and the distal bone plug site should
be chosen with the following considerations:
1. The stem tip should extend beyond major cortical
bone damage, and at least two femoral diameters
beyond major cortical segmental defects.
2. The distal bone plug should be at least 2cm below the
distal extent of the tamp. The tamp is approximately
2cm longer than the corresponding stem. The Distal
Femoral Packer has a single line, labeled “130
PLUG,” “180 PLUG,” etc (Fig. 5).
Fig. 5
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Guide Wire and Intramedullary Bone Plug Insertion
Bone Plug Size
Bone Plug Depth
Use either the Distal Femoral Packers or the Medullary
Canal Sizers to determine the size of the bone plug that will
be stable at the appropriate bone plug depth. The Distal
Femoral Packers can be used to gauge the size of bone plug
required provided the packers can pass distally without
being obstructed by angular deformity of the femur, leading
to a false impression of the size of the femoral canal.
Assuming there is not a need to place the bone plug more
distally because of significant cortical bone damage, the
depth of the Allen Medullary Bone Plug should be 2cm
below the tip of the Distal Tamp (Fig. 6). This depth is
marked on Distal Femoral Packers as “130 Plug,” “180
Plug,” etc. and corresponds to approximately 4cm below
the stem tip. Alternatively, the depth required can be read
by comparing the Medullary Canal Sizer length to the ruler
marks on the packer (Fig. 7).
One technique is to use an Allen Medullary Bone Plug core
diameter equal to the size of the largest Medullary Canal
Sizer that just passes through the narrowed region of the
femur (note that the bone plug core diameter is used and not
the outer flange diameter).
Insertion
Thread the Guide Wire onto the Allen Medullary Bone Plug
and slide the Starter Packer over the Guide Wire (Fig. 8).
Gently tap the Distal Femoral Packer and bone plug to the
selected distal bone plug site and check to ensure that the
bone plug is stable.
4cm
2cm
2cm
Fig. 6
Fig. 7
Fig. 8
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
If the tip of the stem will be below the isthmus, there are a
number of options.
1. Gently tapping the bone plug in place or adding a
second larger bone plug often provides a stable bone
plug.
2. A temporary K-wire can be inserted across the femoral
canal and the bone plug tapped down to rest on the
wire, which is removed at the end of the procedure.
3. A small amount of cement can be used by introducing it
through a cement gun nozzle and placing the bone plug
on top of the polymerized cement.
4. In uncommon situations when the first bone plug is
inadequate but a larger core diameter may not fit, a
larger bone plug can have some of its core and flange
removed with rongeurs so that it passes more easily
through the isthmus, but will still lodge in the femur.
Use of a Bone or Cement Pedestal as a Bone Plug
A distal bone pedestal can be used as a plug if there is not
severe thinning of the cortices immediately above the plug,
which may be prone to fracture. In these cases, remove the
pedestal and bypass the very thin cortices with the stem.
Fig. 9
Similarly, a distal cement plug can be retained and used
if there is not severe osteolysis immediately above it, the
adjacent cortices are not severely thinned, and there has
been no infection.
If a distal bone or cement pedestal is used as a plug and the
center of the pedestal is central in the canal, use the Starter
Packer to centralize the Guide Wire and drill the wire into the
pedestal. If the pedestal is off center, use a narrower packer
to position the distal wire in the appropriate position in the
bone plug.
Distal Graft Packing
Initially introduce 10cc of graft and impact so as to enhance
the bone plug fixation. Then introduce 5cc at a time of
morselized allograft into the femoral canal around the Guide
Wire. Adding too much graft at one time may cause
a void in the graft. Pass the Starter Packer, as determined
on page 17, over the Guide Wire and pack the bone graft
distally with the Starter Packer (Fig. 9). Remove the Starter
Packer and introduce another 5cc of graft. Then reintroduce
the Starter Packer and pack the graft again. Repeat this
procedure until the line on the Starter Packer marked “Distal
Pack” is even with the Bone Reference Point (Fig.10).
Note: If necessary, use a larger diameter Distal Femoral
Packer to match the increasing size of the femoral canal as
the graft builds proximally. Use the measurements made
earlier to avoid inserting a Distal Femoral Packer to a depth
that will impinge on the canal walls.
Fig. 10
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Distal Graft Preparation for a Long Stem Component
If a long stem CPT 12/14 Component will be implanted, use
Distal Femoral Packers to graft up to the Distal Pack level on
the packers. Then use the Graft Corer over the Guide Wire to
remove a central core of impacted distal graft.
Use of the Bone Graft Corers
The Graft Corers can remove a cylindrical plug 10mm or
12mm in diameter and up to 7cm long. The corers can be
used in two different ways, either to remove bone graft that
may inadvertently become trapped in the distal canal during
tamping with standard 130mm length stems, or routinely
to remove distal graft during long stem impaction grafting.
For graft removal during standard 130mm length tamping,
use the 130 tamp etch mark. In general, the 10mm diameter
Graft Corer is recommended for use distally and the 12mm
Graft Corer for use more proximally.
Beginning with the 10mm Graft Corer, attach the corer to a
T-handle (Fig. 11). Insert the corer to the level of the graft
and, while applying pressure, turn the T-handle to penetrate
the impacted graft. Then, without twisting the T-handle,
withdraw the corer to remove the graft core. Use the side slot
in the corer to remove graft for reuse.
The etch marks on the corers provide a reference for
removing allograft plugs. One side is labeled with the tamp
lengths for each stem length and the other side is labeled
with the recommended core depth by stem length. Remove
graft until the “130 CORE,” “180 CORE,” etc., etch mark
reaches the Bone Reference Point (Fig. 12). This will remove
bone to within 4cm of the chosen tamp length.
Fig. 11
Fig. 12
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Impaction with Femoral Tamps
Assemble the predetermined starter Tamp Assembly using
the Locking Screw. This is the largest tamp that previously
fit the femur in correct orientation. Have the assistant
assemble one or two smaller size tamps if it is planned to
decrease the tamp size during impaction, which is routinely
advised for standard length tamp impaction.
Attach the starter Tamp Assembly to the Rasp Handle (Fig.
13a). Do not use the MIS CPT Rasp Handle (8334-81)
with any impaction grafting instruments. Introduce 5cc
of allograft into the femoral canal, and insert the Tamp
Assembly over the Guide Wire. Use a mallet to drive the
tamp into the allograft, being careful to ensure correct
orientation and anteversion, always tending toward a
valgus position (Fig. 13b).
Note: Whether using standard stems or long stems, if any
of the tamps do not advance adequately or fail to seat to
the appropriate depth, remove the Tamp Assembly and
use the 10mm and 12mm Graft Corers to remove distal
bone as necessary (See “Use of the Bone Graft Corers”
above). When using long stems and impaction grafting in
a capacious femur, a wider cavity for cement can be made
with the corers than the tamps, if required. Advance the
10mm Graft Corer the full distance to the designated TAMP
mark on the corer. Advance the 12mm Graft Corer to the
CORE mark, which will be 4cm from the end of the tamp.
Then, continue tamping. A surgeon may then choose to use
a standard cement gun nozzle with a distal outer diameter
of 11.25mm.
Fig. 13a
Remove the Tamp Assembly and insert another 5cc of
allograft. Then reinsert the tamp and impact it again.
Repeat this procedure several times until the entire canal is
lined circum-ferentially with impacted allograft. Check the
orientation of the tamp each time it is inserted to ensure
correct alignment of the prosthesis.
Continue impacting until the Starter Tamp shoulder is
level with the Bone Reference Point and bone graft has
reached the proximal extent of the femur. Once the allograft
has been impacted to the top of the canal, use the next
smallest tamp until the desired tamp size is reached. When
using standard length stems, this is usually one or two
sizes smaller than the first tamp used. The size of the Final
Tamp determines the size of the implant to be used.
Eventually, the femoral canal is solidly and evenly packed
with allograft and the Tamp Assembly has initial stability.
Fig. 13b
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
23
Monoblock Tamping
The advantage of the modular impaction grafting
technique is focused proximal reconstruction. However,
if desired, graft impaction can be completed via a
monoblock tamp technique using the Tamp Assemblies.
Tamp to the Final Tamp and proceed to proximal packing.
Trial Reduction
Remove the Guide Wire and Rasp Handle. Attach the
appropriate Cone Provisional to the trunnion of the tamp
(Fig. 14). Use Table below to determine the appropriate
combination. Attach a Femoral Head Provisional and
perform a trial reduction to check leg length and offset.
If necessary, the leg length may be slightly adjusted by
changing the depth of insertion of the stem at insertion;
however, it is not recommended to seat the stem proud in
impaction grafting procedures.
Note: If using a VerSys Trial Head, refer to the Zimmer
VerSys Trial Head Surgical Technique 97-8018-001-00 for
additional information.
Fig. 14
Available Cone Provisionals
Tamp Assembly Size
Standard Offset
Extended Offset
Extra-Extended Offset
1
1 STD
1 EXT
2
2 STD
2 EXT
2 XEXT
3
3 STD
3 EXT
3 XEXT
4
4 STD
4 EXT
4 XEXT
5
5 STD
5 EXT
5 XEXT
2x180
2 STD
Valgus Neck
2x180 VN
3x180
3 EXT
4x200
4 EXT
4x230
4 EXT
4x260
4 EXT
3x180 VN
24
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Proximal Bone Reconstruction
If depth of insertion or position requires adjustment,
reinsert the guide wire and retamp. Otherwise, leave the
Final tamp in place, modularize the tamp and undertake
proximal graft impaction. If mesh is required to contain the
graft proximally and it has not already been applied, leave
the tamp in place to act as a guide. Apply medial mesh so
the graft is contained up to the neck cut mark.
Modular Tamping
With the Final Tamp in situ, remove the Locking Screw
and thread the Guide Rod Extension through the Proximal
Tamp into the Distal Tamp shaft and tighten gently with
the screwdriver. The single line mark on the Guide Rod
Extension will now be at the level of the superior face of
the tamp. Reattach the Rasp Handle and withdraw the
Proximal Tamp. To pack a large amount of graft proximally,
remove the proximal Tamp and insert graft. Otherwise,
Fig. 15
withdraw the proximal Tamp 3cm to 5cm, stopping
the tamp shoulder before the double-line mark on the
Guide Rod Extension. With the Proximal Tamp withdrawn
approximately 5cm, the Proximal Tamp will still be engaged
on the Distal Tamp and the Distal Tamp acts as a guide
during impaction (Fig. 15). Add 5cc of graft around the
Proximal Tamp and pack this distally with the smaller
Proximal Packer. Impact the proximal Tamp until it reaches
the Distal Tamp indicated by when the single-line mark on
the Guide Rod Extension becomes visible. The Proximal
Tamp has then reached the distal Tamp and impaction is
ceased.
Continue alternating graft insertion and Proximal Tamp
impaction until the proximal canal is evenly and solidly
packed with allograft.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Proximal Packing and Torque Test
Withdraw the Proximal Tamp approximately 1cm, and
use the Proximal Packers to impact cancellous cubes
(5mm x 5mm x 5mm and/or 5mm x 5mm x 10mm) and
smaller allograft pieces (Fig. 16). This will create a stable,
reconstituted bone mantle at the osteotomy level.
Fig. 16
Fig. 17
Use the Proximal Packers only to compress the graft; they
should not be wedged aggressively between the tamp and
the cortex as this may dislodge or push the tamp out of
alignment. Reseat the proximal Tamp down to the distal
Tamp. If desired, the surgeon may perform a torque test to
check rotational stability. Torque test the tamp to 50 in.lbs. by rotating the tamp in a posterior direction (Fig. 17).
A torque wrench and Rasp Handle Adapter are provided
in the CPT 12/14 Impaction Grafting Instrument Set. If the
tamp moves at 50 in.-lbs., perform further impaction.
25
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Reconnect Tamp
Reconnect the Proximal Tamp and Distal Tamp in situ
by removing the Guide Rod Extension and inserting
the Locking Rod through the Proximal Tamp, and then
tightening this into the Distal Tamp with the screwdriver
(Fig. 18). Tap the Tamp assembly out a few millimeters
and then reimpact it and retighten the Locking Rod firmly
with the screwdriver. Check to ensure that the tamp is
at the appropriate depth as determined during the trial
reduction. Then tap the Tamp Assembly out approximately
1cm and gently reseat it by hand so it can be easily
withdrawn immediately prior to cementing.
Guide Rod
Extension
Check to ensure that the inverted Cement Restrictor Plate
or polymer horse collar Cement Restrictor Seal will fit over
the proximal femur and contain graft during cementing,
and trim the polymer horse collar Cement Restrictor Seal if
necessary to fit.
Just prior to cementing, insert a thin suction tube down the
guide wire hole in the tamp to remove blood.
Immediately before cement insertion, carefully remove the
tamp from the neomedullary canal.
Screwdriver
Note: Throughout the impaction grafting procedure, there
is the possibility that graft will become caught between
the proximal and distal Tamps. Use a guide wire, curette,
and saline to clean the instruments.
Locking
Rod
Fig. 18
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Cement Application
For standard 130mm stems and 180mm long stems, use a
cement gun with a small diameter nozzle that has been cut
to the length of the stem. This facilitates cement injection
into the narrow distal stem area. A Miller™ Bone Cement
Injector with a flexible nozzle (00-5069-056-00) with a
9.5mm OD or a Miller Tapered Cement Nozzle (00-5069070-00) which tapers to a 6.1mm OD are recommended.
A Miller Injector with a flexible nozzle (00-5069-054-00)
can be used with the smallest tamp. Trim the nozzle to the
length of the stem.
For size 4 200mm-260mm long stems or any stem where
the 12mm Graft Corer has been used down to near the
distal part of the cement mantle, a standard cement nozzle
can be used to deliver cement to the canal. The cement
nozzle has a distal outer diameter of 11.5mm, and gently
tapers proximally.
Fill the canal in a retrograde fashion without disturbing the
impacted bone graft.
Use the polymer horse collar Cement Restrictor Seal, which
may be trimmed to fit over the proximal femur, to contain
graft during cement injection. One useful technique is to
apply the horse collar and inject the cement in a retrograde
fashion through the collar or an inverted Cement Restrictor
Plate. When the canal is filled, break off the cement
nozzle and inject additional cement through the Femoral
Pressurizer Seal (Fig. 19). It is also acceptable to apply the
CPT Cement Pressurizer directly to the allograft, thus forcing
the cement into the allograft and maintaining pressure until
the cement reaches a doughy state.
Fig. 19
Implantation
Attach the distal centralizer to the femoral stem (Fig. 20)
with a twisting motion. Two distal centralizers are available.
For impaction grafting applications, the wingless Revision
Distal Centralizer is recommended. It is not packaged with
the stem, but is available individually sterile packaged. If
only the Standard Distal Centralizer is available, remove
the wings to prevent disruption of the graft as the stem is
inserted.
Fig. 20
27
28
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Attach the femoral component to the Stem Inserter by
placing the release lever in the engage position, marked
“E” and turning the barrel to thread the inserter onto the
stem (Fig. 21). A small pin engages the dimple on the
stem shoulder to control component anteversion during
insertion.
Introduce the stem through the polymer horse collar
Cement Restrictor Seal (Fig. 22). Place the thumb or finger
over the medial anterior femoral neck while inserting
the stem to maintain cement pressure and to ensure
that the stem does not move into varus. There should be
approximately 5mm of cement on the medial side of the
stem.
Fig. 21
Fig. 22
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
Slowly advance the stem into the cement mantle. The Stem
Inserter has a mark along the stem center line to aid in
insertion (Fig. 23). The Stem Inserter also has a threaded
hole between the handle and barrel to assemble an
anteversion rod.
The Tamp Extractor Rod may be used as
an anteversion rod. The anteversion rod may be assembled
on either side and represents a reference for zero degrees
of anteversion. Slowly advance the stem into the cement
mantle. Insert the stem to the final position using the
osteotomy etch mark and stabilize the stem with one hand
while removing the inserter with the other.
Note: Impacting the stem with a mallet should be
avoided, but can be used if necessary. One technique
is for the surgeon to maintain the stem orientation and
anteversion while an assistant taps the stem into position.
It is recommend to gently push a small amount of cement
over the lateral shoulder of the stem (Fig. 24). This helps
prevent the remote possibility that the stem will back out
inadvertently should a postoperative dislocation require
reduction.
A small amount of cement may also be left over the
proximal graft so that the graft is contained and not
affected by cleaning lavage of the hip. Gently remove
excess cement. If not already applied, place the polymer
horse collar Cement Restrictor Seal around the proximal
body of the stem to apply pressure until the cement is set.
Fig. 23
Once the cement has hardened, the Femoral Head
Provisional may be used to confirm final femoral head
size. Assess the leg length, range of motion, stability, and
abductor tension one final time.
Note: If using a VerSys Trial Head, refer to the Zimmer
VerSys Trial Head Surgical Technique 97-8018-001-00 for
additional information.”
Verify that the neck taper is clean and dry. Assemble the
femoral head on the taper and impact the head with the
femoral head impactor. Test the security of the head
fixation by trying to remove it by hand.
Wound Closure
After obtaining hemostasis, insert a Hemovac® Wound
Drainage Device, if desired. Then close the wound in layers.
Fig. 24
29
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CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
REFERENCES
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2. Capello WN. Impaction grafting plus cement for femoral component fixation
in revision hip arthroplasty. Orthopedics. 1994;17(9):878-879. No abstract
available.
3. Elting JJ, Mikhail WEM, Zicat BA, Hubbell JC, Lane LE, House B. Preliminary
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4-year follow-up of 10 patients. Arch Orthop Traumat Surg. 2000;120(7-8):386389.
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28. Robinson DE, Lee MB, Smith EJ, Learmonth ID. Femoral impaction grafting in
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30. Knight JL, Helming C. Collarless polished tapered impaction grafting of the femur
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10. Mikhail WEM, Wretenberg PF, Weidenhielm LR, Mikhail MN. Complex cemented
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cement mantle in femoral impaction allografting. A comparison of three systems
from four centres. J Bone Joint Surg (Br). 1997;79(6):908-913.
11. Piccaluga F, Gonzalez Della Valle A, Encinas Fernandez JC, Pusso R. Revision of
the femoral prosthesis with impaction allografting and a Charnley stem: a 2- to
12-year follow-up. J Bone Joint Surg (Br). May 2002;84(4):544-549.
32. Nelissen RGHH, Valstar ER, Poll RG, Garling EH, Brand R. Factors associated with
excessive migration in bone impaction hip revision surgery: a radiostereometric
analysis study. J Arthroplasty. 2002;17(7):826-383.
12. van Biezen FC, ten Have BL, Verhaar JA. Impaction bone-grafting of severely
defective femora in revision total hip surgery: 21 hips followed for 41-85 months.
Acta Orthop Scand. 2000;71(2):135-142.
33. Stulberg SD. Impaction grafting: doing it right. J Arthroplasty. 2002;17(4 Suppl
1):147-152.
13. van Doorn WJ, ten HB, van Biezen FC, Hop WC, Ginai AZ, Verhaar JA. Migration
of the femoral stem after impaction bone grafting: first results of an
ongoing, randomised study of the exeter and elite plus femoral stems using
radiostereometric analysis. J Bone Joint Surg (Br). 2002;84(6):825-831.
14. Weidenhielm LRA, Mikhail WEM, Nelissen RGHH, Bauer TW. Surgical technique
and early results in revision of a total hip arthroplasty with a cemented,
collarless, tapered, polished stem, and contained morselized allograft. J Orthop
Techniques. 1994;2(3):113-122.
15. Eldridge JD, Smith EJ, Hubble MJ, Whitehouse SL, Learmonth ID. Massive early
subsidence following femoral impaction grafting. J Arthroplasty. 1997;12(5):535540.
16. Leopold SS, Berger RA, Rosenberg AG, Jacobs JJ, Quigley LR, Galante JO. Impaction
allografting with cement for revision of the femoral component: a minimum fouryear follow-up study with use of a precoated femoral stem. J Bone Joint Surg.
1999;81(8):1080-1092.
17. Pekkarinen J, Alho A, Lepisto J, Ylikoski M, Ylinen P, Paavilainen T. Impaction bone
grafting in revision hip surgery. A high incidence of complications. J Bone Joint
Surg (Br). 2000;82(1):103-107.
18. Linder L. Cancellous impaction grafting in the human femur: histological and
radiographic observations in 6 autopsy femurs and 8 biopsies. Acta Orthop
Scand. 2000;71(6):543-552.
19. Mikhail WEM, Weidenhielm LR, Wretenberg P, Mikhail MN, Bauer TW. Femoral
bone regeneration subsequent to impaction grafting during hip revision:
histologic analysis of a human biopsy specimen. J Arthroplasty. 1999;14(7):849853.
20. Nelissen RGHH, Bauer T, Weidenhielm LRA, LeGolvan DP, Mikhail WEM, Revision
hip arthroplasty with the use of cement and impaction grafting. J Bone Joint Surg.
1995;77-A(3):412-422.
34. Duncan CP, Masterson EL, Masri BA. Impaction allografting with cement for the
management of femoral bone loss. Orthop Clin N Am. 1998;29(2):297-305.
Review. PMID: 9553574 [PubMed - indexed for MEDLINE]
35. Barden B, Von Knoch M, Fitzek JG, Loer F. Periprosthetic fractures with extensive
bone loss treated with onlay strut allografts. Internat Orthop. 2003.
36. Gore DR. Impaction bone grafting for total hip revision. Int Orthop.
2002;26(3):162-165.
37. Weidenhielm LRA, Mikhail WEM, Nelissen RGHH, Bauer TW. Cemented collarless
(Exeter-CPT) femoral components versus cementless collarless (PCA) 2-14 year
follow-up evaluation. J Arthroplasty. 1995;10(5):592-597.
38. Malchau H, Herberts P. Prognosis of total hip replacement. Scientific Exhibition:
65th Annual Meeting of The American Academy of Orthopaedic Surgeons; 1998;
New Orleans, Louisiana.
39. Fowler JL, Gie GA, Lee AJC, Ling RSM. Experience with the Exeter total hip
replacement since 1970. Orthop Clin N Am. 1988;19:477.
40. Yates P, Gobel D, Bannister G. Collarless polished tapered stem. J Arthroplasty.
2002;17(2):189-195.
41. Danish Hip Arthroplasty Registry, Annual Report, Aarhus University Hospital,
Department of Orthopaedic Surgery, 2002.
42. Data on file at Zimmer.
43. Howie D, McGee M, Costi C, Ward P, Fairbank A. Comparison of clinical and
radiological outcomes of revision total hip replacement using cement,
cementless and hybrid fixation. Presented at: SICOT/SIROT 2002 World Congress,
San Diego, CA, 212f.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
31
C
E
B
D
A
CTP 12/14 Hip Prosthesis
Prod. No.
Standard Offset
00-8114-000-00
00-8114-001-00
00-8114-002-00
00-8114-003-00
00-8114-004-00
00-8114-005-00
Stem
Size (mm)
A
Stem
Length (mm)
B
Offset (mm)
When Head/Neck
Component Selected is:
0
+3.5
+7
32
35
37
34
37
39
36
38
41
37
40
43
38
41
44
40
43
45
+10.5
40
42
44
46
46
48
-3.5
24
24
24
24
24
24
C
Neck Height (mm)
When Head/Neck
Component Selected is:
0
+3.5
+7
26
28
30
26
28
30
26
28
30
26
28
30
26
28
30
26
28
30
D
E
A/P Width
M/L Width
+10.5
32
32
32
32
32
32
7.5
9.0
9.0
9.0
10.0
10.0
9.0
10.5
13.0
15.5
17.5
20.0
0-STD
1-STD
2-STD
3-STD
4-STD
5-STD
105
130
130
130
130
130
-3.5
29
31
33
35
35
37
Extended Offset
00-8114-000-10
00-8114-001-10
00-8114-002-10
00-8114-003-10
00-8114-004-10
00-8114-005-10
0-EXT
1-EXT
2-EXT
3-EXT
4-EXT
5-EXT
105
130
130
130
130
130
34
36
38
40
40
42
37
39
41
42
43
45
40
42
43
45
46
47
42
44
46
48
48
50
45
47
49
51
51
53
24
24
24
24
24
24
26
26
26
26
26
26
28
28
28
28
28
28
30
30
30
30
30
30
32
32
32
32
32
32
7.5
9.0
9.0
9.0
10.0
10.0
9.0
10.5
13.0
15.5
17.5
20.0
Extra Extended Offset
00-8114-002-30
00-8114-003-30
00-8114-004-30
00-8114-005-30
2-XEXT
3-XEXT
4-XEXT
5-XEXT
130
130
130
130
43
45
45
47
46
47
48
50
48
50
51
52
51
53
53
55
54
56
56
58
29
29
29
29
31
31
31
31
33
33
33
33
35
35
35
35
37
37
37
37
9.0
9.0
10.0
10.0
13.0
15.5
17.5
20.0
Small
00-8114-040-00
00-8114-05-00
X-Small
Small
85
95
25
27
28
30
31
33
34
36
37
39
21
22
23
24
25
26
27
28
29
30
7.0
7.5
8.0
9.0
Revision - Long
00-8114-002-18
00-8114-012-18
00-8114-003-18
00-8114-013-15
00-8114-004-20
00-8114-004-23
00-8114-004-26
2, 180
2, 180 VN
3, 180
3, 180 VN
4, 200
4, 200
4, 260
180
180
180
180
200
230
260
33
33
40
40
40
40
40
36
36
42
42
43
43
43
38
38
45
45
46
46
46
41
41
48
48
49
49
49
44
44
51
51
51
51
51
24
39
24
39
24
24
24
26
41
26
41
26
26
26
28
43
28
43
28
28
28
30
45
30
45
30
30
30
32
47
32
47
32
32
32
9.5
9.5
9.5
9.5
11.0
11.0
11.0
13.0
13.0
16.0
16.0
16.0
16.0
16.0
32
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
CoCr Femoral Head Options
Prod. No.
Description
00-8018-022-20 Fem Head -2 x 22mm Dia
00-8018-022-02 Fem Head 0 x 22mm Dia
00-8018-022-30 Fem Head +3 x 22mm Dia
00-8018-026-01 Fem Head -3.5 x 26mm Dia
00-8018-026-02 Fem Head 0 x 26mm Dia
00-8018-026-03 Fem Head +3.5 x 26mm Dia
00-8018-026-04 Fem Head +7 x 26mm Dia
00-8018-026-05 Fem Head +10.5 x 26mm Dia
00-8018-028-01 Fem Head -3.5 x 28mm Dia
00-8018-028-02 Fem Head 0 x 28mm Dia
00-8018-028-03 Fem Head +3.5 x 28mm Dia
00-8018-028-04 Fem Head +7 x 28mm Dia
00-8018-028-05 Fem Head +10.5 x 28mm Dia
00-8018-032-01 Fem Head -3.5 x 32mm Dia
00-8018-032-02 Fem Head 0 x 32mm Dia
00-8018-032-03 Fem Head +3.5 x 32mm Dia
00-8018-032-04 Fem Head +7 x 32mm Dia
00-8018-032-05 Fem Head +10.5 x 32mm Dia
00-8018-036-01 Fem Head -3.5 x 36mm Dia
00-8018-036-02 Fem Head 0 x 36mm Dia
00-8018-036-03 Fem Head +3.5 x 36mm Dia
00-8018-036-04 Fem Head +7 x 36mm dia
00-8018-036-05 Fem Head +10.5 x 36mm Dia
00-8018-040-01 Fem Head -3.5 x 40mm Dia
00-8018-040-02 Fem Head 0 x 40mm Dia
00-8018-040-03 Fem Head +3.5 x 40mm Dia
00-8018-040-04 Fem Head +7 x 40mm Dia
00-8018-040-05 Fem Head +10.5 x 40mm Dia
Ceramic Femoral Head Options*
Prob. No.
Description
00-8775-028-01 BIOLOX delta Ceramic Femoral Head -3.5x28mm
00-8775-028-02 BIOLOX delta Ceramic Femoral Head 0x28mm
00-8775-028-03 BIOLOX delta Ceramic Femoral Head +3.5x28mm
00-8775-032-01 BIOLOX delta Ceramic Femoral Head -3.5x32mm
00-8775-032-02 BIOLOX delta Ceramic Femoral Head 0x32mm
00-8775-032-03 BIOLOX delta Ceramic Femoral Head +3.5x32mm
00-8775-032-04 BIOLOX delta Ceramic Femoral Head +7x32mm
00-8775-036-01 BIOLOX delta Ceramic Femoral Head -3.5x36mm
00-8775-036-02 BIOLOX delta Ceramic Femoral Head 0x36mm
00-8775-036-03 BIOLOX delta Ceramic Femoral Head +7x36mm
00-8775-036-04 BIOLOX delta Ceramic Femoral Head -3.5x40mm
00-8775-040-01 BIOLOX delta Ceramic Femoral Head -3.5x40mm
00-8775-040-02 BIOLOX delta Ceramic Femoral Head 0x40mm
00-8775-040-03 BIOLOX delta Ceramic Femoral Head +3.5x40mm
00-8775-040-04 BIOLOX delta Ceramic Femoral Head +7x40mm
00-8777-028-01 BIOLOX delta Option Femoral Head, -3.0x28mm
00-8777-028-02 BIOLOX delta Option Femoral Head, +0x28mm
00-8777-028-03 BIOLOX delta Option Femoral Head, +3.5x28mm
00-8777-028-04 BIOLOX delta Option Femoral Head, +7x28mm
00-8777-032-01 BIOLOX delta Option Femoral Head, -3.0x32mm
00-8777-032-02 BIOLOX delta Option Femoral Head, +0x32mm
00-8777-032-03 BIOLOX delta Option Femoral Head, +3.5x32mm
00-8777-032-04 BIOLOX delta Option Femoral Head, +7x32mm
00-8777-036-01 BIOLOX delta Option Femoral Head, -3.0x36mm
00-8777-036-02 BIOLOX delta Option Femoral Head, +0x36mm
00-8777-036-03 BIOLOX delta Option Femoral Head, +3.5x36mm
00-8777-036-04 BIOLOX delta Option Femoral Head, +7x36mm
00-8777-040-01 BIOLOX delta Option Femoral Head, -3.0x40mm
00-8777-040-02 BIOLOX delta Option Femoral Head, +0x40mm
00-8777-040-03 BIOLOX delta Option Femoral Head, +3.5x40mm
00-8777-040-04 BIOLOX delta Option Femoral Head, +7x40mm
12.28.05
BIOLOX forte Ceramic Femoral Head -3.5x28mm
12.28.06
BIOLOX forte Ceramic Femoral Head 0x28mm
12.28.07
BIOLOX forte Ceramic Femoral Head +3.5x28mm
12.32.05
BIOLOX forte Ceramic Femoral Head -3.5x32mm
12.32.06
BIOLOX forte Ceramic Femoral Head 0x32mm
12.32.07
BIOLOX forte Ceramic Femoral Head +3.5x32mm
00-6428-028-01 Alumina Ceramic Femoral Head -3.5x28mm
00-6428-028-02 Alumina Ceramic Femoral Head 0x28mm
00-6428-028-03 Alumina Ceramic Femoral Head +3.5x28mm
00-6428-032-01 Alumina Ceramic Femoral Head -3.5x32mm
00-6428-032-02 Alumina Ceramic Femoral Head 0x32mm
00-6428-032-03 Alumina Ceramic Femoral Head +3.5x32mm
* BIOLOX® is a trademark of CeramTec GmbH
CPT Distal Centralizers
Prod. No.
Description
32-8334-055-00 Primary Distal Centralizer
32-8334-056-00 Revision Distal Centralizer
00-8334-000-01
Prod. No.
00-8334-030-00
00-8334-014-00
31-8334-005-00
00-6601-054-00
00-6601-056-00
00-8334-065-00
00-8334-065-01
00-8334-065-02
00-8334-050-00
00-8334-010-00
00-8334-011-00
00-8334-013-00
00-8334-060-00
00-8334-060-01
00-8334-060-02
00-8334-060-03
00-8334-060-40
00-8334-060-50
31-8334-013-00
00-8334-080-10
00-8334-015-00
00-8334-015-01
00-8334-015-02
00-8334-015-03
00-8334-020-00
00-8334-020-01
00-8334-020-02
00-8334-020-03
00-8334-025-02
00-8334-025-03
00-8334-015-40
00-8334-015-50
00-8334-061-00
00-8334-062-00
00-8334-070-54
00-9027-058-00
CPT Extra Small-Size 3 Instrument Set
Description
General Instrument Set Case Assembly
Osetotomy Guide
Stem Extractor Adapter
Box Osteotome, Small
Box Osteotome, Large
Starter Awl, 8mm
Medium Awl, 11mm dia
Larger Awl, 14mm dia
Extra Small-Size 3 Instrument Case Assembly
Rasp Handle
Trial Locating Pin
Stem Inserter
Size 0 Rasp
Size 1 Rasp
Size 2 Rasp
Size 3 Rasp
Small Rasp
Extra Small Rasp
Cement Restrictor Plate
Femoral Pressurizer Plate
Size 0 Std Cone Prov
Size 1 Std Cone Prov
Size 2 Std Cone Prov
Size 2 Std Cone Prov
Size 0 Ext Cone Prov
Size 1 Ext Cone Prov
Size 2 Ext Cone Prov
Size 3 Ext Cone Prov
Size 2 X-Ext Cone Prov
Size 3 X-Ext Cone Prov
Extra Small Stem Prov
Small Stem Prov
Allen Plug Inserter
Stem Inserter Adapter
Tamp Extractor Rod
Femoral Head Impactor
00-8334-000-05 CPT Extra Small/Small Supplementary Instrument Set
Prod. No.
Description
00-8334-045-00 Extra Small/Small Instrument Case Assembly
00-8334-060-40 Extra Small Rasp
00-8334-060-50 Small Rasp
00-8334-015-40 Extra Small Stem Prov
00-8334-015-50 Small Stem Prov
00-7895-022-20 Fem Head Prov, 22mm -2
00-7895-022-02 Fem Head Prov, 22mm +0
00-7895-022-30 Fem Head Prov, 22mm +3
This is to be used with the Primary Instrument Set.
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
00-8334-000-02
Prod. No.
00-8334-030-00
00-8334-014-00
31-8334-005-00
00-6601-054-00
00-6601-056-00
00-8334-065-00
00-8334-065-01
00-8334-065-02
00-8334-035-00
00-8334-010-00
00-8334-011-00
00-8334-013-00
00-8334-060-00
00-8334-060-01
00-8334-060-02
00-8334-060-03
00-8334-060-04
00-8334-060-05
31-8334-013-00
00-8334-080-10
00-8334-015-00
00-8334-015-01
00-8334-015-02
00-8334-015-03
00-8334-015-04
00-8334-015-05
00-8334-020-00
00-8334-020-01
00-8334-020-02
00-8334-020-03
00-8334-020-04
00-8334-020-05
00-8334-025-02
00-8334-025-03
00-8334-025-04
00-8334-025-05
00-7895-028-01
00-7895-028-02
00-7895-028-03
00-7895-028-04
00-7895-028-05
00-8334-061-00
00-8334-062-00
00-8334-070-54
00-9027-058-00
CPT Primary Instrument Set
Description
General Instrument Case Assembly
Osteotomy Guide
Stem Extractor Adapter
Box Osteotome, Sm
Box Osteotome, Lrg
Starter Awl, 8mm
Medium Awl, 11mm dia
Large Awl, 14mm dia
Primary Instrument Case Assembly
Rasp Handle
Trial Locking Pin
Stem Inserter
Size 0 Rasp
Size 1 Rasp
Size 2 Rasp
Size 3 Rasp
Size 4 Rasp
Size 5 Rasp
Cement Restrictor Plate
Femoral Pressurizer Plate
Size 0 Std Cone Prov
Size 1 Std Cone Prov
Size 2 Std Cone Prov
Size 3 Std Cone Prov
Size 4 Std Cone Prov
Size 5 Std Cone Prov
Size 0 Ext Cone Prov
Size 1 Ext Cone Prov
Size 2 Ext Cone Prov
Size 3 Ext Cone Prov
Size 4 Ext Cone Prov
Size 5 Ext Cone Prov
Size 2 X-Ext Cone Prov
Size 3 X-Ext Cone Prov
Size 4 X-Ext Cone Prov
Size 5 X-Ext Cone Prov
Fem Head Prov, 28mm -3.5
Fem Head Prov, 28mm +0
Fem Head Prov, 28mm +3.5
Fem Head Prov, 28mm +7
Fem Head Prov, 28mm +10.5
Allen Plug Inserter
Stem Inserter Adapter
Tamp Extractor Rod
Femoral Head Impactor
00-8334-000-03 CPT Revision Supplementary Instrument Set
Prod. No.
Description
00-8334-040-00 Revision Instrument Case Assembly
00-8334-060-22 Size 2 Rasp, 180mm
00-8334-060-23 Size 3 Rasp, 180mm
00-8334-060-24 Size 4 Rasp, 200mm
00-8334-070-25 Size 4 Stem Prov, 230mm
00-8334-070-26 Size 4 Stem Prov, 260mm
00-8334-026-02 Size 2 Valgus Nk Cone Prov
00-8334-026-03 Size 3 Valgus Nk Cone Prov
This is to be used with the Primary Instrument Set.
00-8334-000-04 CPT Impaction Grafting Instrument Set
Prod. No.
Description
00-8334-055-00 Impaction Grafting Instrument Case Assembly
00-8334-060-30 Guide Wire, 400mm
00-8334-060-35 Guide Wire, 530mm
00-8334-070-01 Size 1 Tamp Assembly
00-8334-070-02 Size 2 Tamp Assembly
00-8334-070-03 Size 3 Tamp Assembly
00-8334-070-04 Size 4 Tamp Assembly
00-8334-070-05 Size 5 Tamp Assembly
00-8334-070-22 Size 2 180mm Tamp Assembly
00-8334-070-23 Size 3 180mm Tamp Assembly
00-8334-070-24 Size 4 200mm Tamp Assembly
00-8334-070-28 Size 4 230mm Distal Tamp
00-8334-070-29 Size 4 260mm Distal Tamp
00-8334-070-51 Guide Rod Extension Rod
00-8334-070-52 Locking Rod
00-8334-070-53 Graft Corer, 10mm
00-8334-070-54 Tamp Extractor Rod
00-8334-070-55 Locking Screw (3)
00-8334-070-56 Graft Corer, 12mm
00-8334-085-01 Curved Proximal Packer, Small
00-8334-085-10 Proximal Packer, Extra-Small
00-8334-085-11 Proximal Packer, Small
00-8334-071-10 Distal Femoral Packer, 10mm
00-8334-071-12 Distal Femoral Packer, 12mm
00-8334-071-14 Distal Femoral Packer, 14mm
00-8334-071-16 Distal Femoral Packer, 16mm
00-1179-094-00 3.5mm Screwdriver QC, 305mm Long
00-4817-090-00 Quick Connect Handle
00-4817-090-00 Universal Chuck with T-Handle
00-6601-030-00 Torque Wrench 3/8 Drive
00-6631-055-00 Torque Wrench Adapter
00-9986-040-11 Zimmer T-Handle
Sterile Pack Items
Prod. No.
Description
32-8334-010-01 Femoral Pressurizer Seal, Sm
32-8334-010-02 Femoral Pressurizer Seal, Lrg
00-8334-084-01 MIS Pressurizer, Small
00-8334-084-03 MIS Pressurizer, Medium
00-8334-084-03 MIS Pressurizer, Large
00-8334-084-51 MIS Pressurizer, Small (5 pack)
00-8334-084-52 MIS Pressurizer, Medium (5 pack)
00-8334-084-53 MIS Pressurizer, Large (5 pack)
33
34
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
CPT® 12/14 Hip System Femoral Impaction Grafting in Revision THR Surgical Technique
35
DISCLAIMER:
This documentation is intended exclusively for physicians and is not intended for
laypersons. Information on the products and procedures contained in this document is
of a general nature and does not represent and does not constitute medical advice or
recommendations. Because this information does not purport to constitute any diagnostic
or therapeutic statement with regard to any individual medical case, each patient must be
examined and advised individually, and this document does not replace the need for such
examination and/or advise in whole or in part.
Please refer to the package inserts for important product information, including, but not
limited to, indications, contraindications, warnings, precautions, and adverse effects.
Contact your Zimmer representative or visit us at www.zimmer.com
The CE mark is valid only if it is also printed on the product label.
97-8114-004-00 Rev. 2 Aug. 2015 Printed in USA ©2015 Zimmer, Inc.